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WELL/PUMP PERMIT <br />J SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />AVA <br />NUM -11 FUNDABLE PERMIT GALL (LUV) VOJ-16V/ FOR INSPECTIONS tAt'IKtb l TEAR FROM DATE ISSUED <br />JOB ADDRESS 16590 S. Murphy Rd. <br />cmy/zip Escalon 95320 <br />CROSS STREET S. of Louise Ave. APN 203-220-01 <br />PARCEL SIZE 40 LAND USE APPLICATION # <br />OWNER NAME Hendley Farming, Inc. <br />PHONE 209-985-4955 <br />OWNER ADDRESS 16590 S. Murphy Rd. <br />CITY/sTATE/ZIP Escalon. CA 95320 <br />CONTRACTOR Hennings Bros. Drillinq Co., Inc. <br />PHONE 209-545-1185 <br />CONTRACTOR ADDRESS 1930 Ladd Rd. <br />CITY/STATE/ZIP Modesto, CA 95356 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE21P <br />LICENSE XC -57 IG•61 D-09 Other NUMBER 290813 EXPIRATION DATE 5-31-18 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE I. Domestic/Private iXlnigation/Agricuhural I I Industrial j Water Quality Monitoring i.! Soil Sampling/Characterization <br />I I Public Water System <br />If different from Owner: a er ys em ame contact Nonne or Phone Number <br />HYPE OF WORK XNew Well i. ReDlacement Well i Well Alteration/Modification i Other <br />Monitoring Well(s) # of wells i Soil Boring(s) If of borings i Geotechnical sof bodngs <br />Out -Of -Service Well I Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point X Other Reverse Rotary <br />Proposed Well Depth 400 it Excavation 22 in diameter 1 Open Bottom X Gravel Pack/Gravel Size #6 in diameter <br />r Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter 12 in Thickness/Gauge/ASTM Sched SDR21 ❑ Steel XPlastic Stainless Steel r_ Other <br />Grout Seal Depth 50 ft Neat Cement (94 Ib bagl5-10 gal water) I Sand Cement sack mix17 gal water <br />XBentonite (20% solids) I Other <br />Grout Placement Method iXPumped 7 Free Fall I Other I-1 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller dump Contractor i Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in 1 1 Christy Box i Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />R <br />q FcF/l;�N' <br />210 <br />0 N NS Oozy <br />Fp�FNp�tiry <br />�FNr <br />DEPARTMENT�]U�S/E ONLY If nn <br />Application Accepted By Date '/'"l ' 0 Areae Employee ID# � A n •, `e/ <br />Grout Inspection By Date SPECIAL WBII Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />PE SC Received Che <br />Codes Info B ash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />+0� 0 <br />3�1qq/16 <br />vi Gbo-Z& <br />EHD 43-06 <br />8104!06 <br />WELL /PUMP PERMIT <br />